Job Description

What will you do?

Under the general direction of the Manager, Ontario Health atHome and in accordance with the Ontario Health atHome Champlain standards, legislation, policies and guidelines, the Care Coordinator is responsible for client assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all client service programs (home care and placement), including the provision of community resource information and referral.

As a member of the care team, the Care Coordinator will provide a broad scope of connection in their caseload geography, linking with care and services beyond community care while partnering closely with patients, families, caregivers, service providers and other community health providers supporting the patient in their home environment. The Care Coordinator may also provide support to Primary Care teams strengthening the relationship and improving communication and access to care for shared patients as well as new patients. Care Coordinator will work collaboratively with patients, families, caregivers, and hospital partners to develop a care plan to support a safe transfer from hospital to home for both complex and non-complex patients. Care Coordinators must prioritize work based on the ever changing needs of patients and hospital environment while meeting the Ontario Health atHome Champlain Guidelines of Care. The Care Coordinator will participate in various meetings to support care planning and communication with partners within the circle of care, including family meetings, care conferences, bullet rounds, and joint discharge rounds.

Primary Responsibilities:

• Completes comprehensive patient assessments using a validated assessment tool, including patient's clinical, physical and psychosocial needs, and caregiver needs
• Assesses the patient's and caregiver's understanding of, and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms
• Assists patient and caregiver in setting appropriate goals (individual, joint, short or long term)
• Collaborates with patient, caregiver and the care team to develop an individualized care and service plan reflective of the patient's identified priorities and desired outcomes; identifies strategies and resources to be used in attaining clinical outcomes
• Coordinates the delivery of Home and community care services to patients and their caregivers
• Coordinates vendor and resource utilization involving medical equipment, supplies and services
• Facilitates understanding and cooperation among members of the patient's multidisciplinary healthcare team; communicates with members of the patient's health care team to maximize patient outcomes
• Initiates and authorizes the implementation of the care plan through contracted providers
• Provides regular reports to Physicians, service providers, patients, caregivers and other authorized parties as required
• Case documentation in accordance with Ontario Health atHome Champlain policies
• Identification and Engagement - Assesses referred clients for admission and establishes a helping relationship with eligible clients and their families while honoring the client's values and preferences
• Assessment - Performs multi-dimensional assessment and identifies the need for crisis intervention and/or prevention strategies
• Goal Setting and Service Planning - Establishes a care and service plan balancing client's needs, choices and available resources.
• Develops a care plan in collaboration with the client, other health care professionals, care providers or family, stating priorities, services authorized, mutual goals and anticipated duration of service
• Accessing Resources and Linking - Collaborates and partners with the networks of service providers.
• Service Implementation - Initiates and authorizes the implementation of the care plan
• Accountability, Monitoring and Reassessment - Reviews and maintains care plan in compliance to quality standards, outcome measures, quality indicators
• Discharge Planning - Conducts discharges from service process and/or redirects clients and families to alternative resources

Department: Eastern Ottawa

Hours in a Biweekly Period: 8:30am - 4:30pm, Monday to Friday (35-hours/week)

FTE: 1.0

Salary Range: $44.480/hr - $47.517/hr

Reports To: Manager, Patient Services

Union Affiliation: ONA

Location: Labelle
Caseload Geography: Supporting both hospital and community.

What must you have?

• Registered Nurse (BScN or diploma) and registered with the College of Nurses of Ontario; or
• Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
• Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
• Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers; or
• Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario; or
• Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
• All of the above require at least 2 years related professional experience
• We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

Knowledge:

• Knowledge of health care delivery system and community resources within the Champlain region
• Medical conditions and cognitive/psychiatric disorders
• Client centered, multi-disciplinary team approach to client care
• Proficient in the use of computerized processes including the use of mobile (laptop) technology

Skills and Abilities:

• Demonstrates effective time management and organizational skills
• Effective decision-making and problem-solving in crisis situations
• Ability to negotiate and implement an effective goal-oriented, client-centered care plan
• Team player with ability to accept and adapt to change
• Ability to maintain a positive attitude in stressful situations
• Ability to organize daily workload in the presence of frequent interruptions
• Fluency in English and French is required.
• Vulnerable Sector Check completed within the last six months
• Valid N95 Mask Fit Test results or documentation of a medical exception within the past two years

Hours of Work

Monday to Friday - 8:30am to 4:30pm (35hrs/week)

What do we offer?

We know wellness is supported with work-life balanceIn an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer:

• Attractive comprehensive compensation packages and benefits
• Valuable development opportunities
• Membership in a world class defined benefit pension plan
• Salary: $44.480/hr to $47.517/hr

This job posting is for an exisiting vacancy.